Gout

Source: https://www.essentialevidenceplus.com/content/eee/699

Source: https://www.essentialevidenceplus.com/content/eee/699

 

 

 

Diagnostic Criteria for Gout:

Diagnosis of gout can be made clinically with the presence of at least 6 of these 12 features:

·         Recurrent arthritic attack

·         Maximal inflammation develops within 24 h

·         Monarticular arthritis

·         Joint redness

·         Pain or swelling in the first MTP joint

·         Unilateral attack involving first MTP

·         Unilateral attack involving tarsal joint

·         Suspected tophus

·         Hyperuricemia

·         Asymmetric swelling within a joint (radiograph)

·         Subcortical cysts without erosions (radiograph)

·         Negative culture of joint fluid

Data from Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 1977;20:895-900.

Drug Treatment for Gout:

Drug

Dose SORT
Acute Treatment
Indomethacin 12 150-200 mg in 2-4 divided doses daily for 3 d, then 100 mg daily in divided doses for 4-7 d, then taper over 2 d B
***Colchicine 43 ***0.6mg tab2 tablets right now (with acute pain) and 1 tab in 1 hr. B
Oral prednisone 19 19 20-50 mg/d for first few days, then tapered over 10 d C
Intra-articular steroid injections (triamcinolone or methylprednisolone) 20-40 mg dose. Treatment of choice when NSAIDs, colchicine, or oral steroids are contraindicated C
Intramuscular methylprednisolone44 80-120 mg C
ACTH 45 40-80 IU IM every 8 h. Usually 2-3 injections required C
Chronic Urate-Lowering Therapy
Allopurinol Start at 100 mg daily and titrate upward every 2 weeks by 50-100 mg increments until target urate levels reached; maximum dose 800 mg daily. Adjust dose in renal insufficiency B
Probenecid Start 250 mg twice daily; maintenance therapy 500-1000 mg 2-3 times daily. If urinary uric acid level over 700 mg, best to use allopurinol to avoid ureteral stones. Contraindicated in patients with past nephrolithiasis and CrCl <50 mL/min B

Colchicine 0.6mg tab:

  • Give 2 tablets (1.2mg) PO X 1 dose now and then 1 tablet (0.6mg) in 1 hour if pain has not resolved.
    • Patient can be discharged on the following prescriptions:
      • CochicineProbenecid 0.5mg-500mg tab – Take 1 tab PO qd
      • Methylprednisolone (Medrol dosepack) 4mg PO qd
  • Sudden onset of severe inflammatory arthritis in a peripheral joint with history of similar attacks separated by asymptomatic periods is suggestive. C
  • Direct visualization of MSU (monosodium urate) crystals in joint aspirate with polarized light microscopy is diagnostic. A
    • MSU crystals in synovial fluid or tophi confirmed with crystal examination
  • The diagnosis is made by clinical criteria and/or direct visualization of monosodium urate (MSU) crystals from joint aspirate. C
  • Serum uric acid is useful but should not be used alone to confirm or exclude the diagnosis. C
  • Disorders and health habits that increase the uric acid pool (eg, obesity, alcohol use) increase a patient’s risk of gout. B
  • There is no need to treat asymptomatic hyperuricemia. B
  • **The acute treatment goal is relief of pain using NSAIDs, colchicine, or steroids. B
  • Antihyperuricemic therapy (ex: Allopurinol) is recommended in patients with a history of gout who have recurrent gouty attacks, tophi, or joint damage on x-ray. B

Prevention:

  • Limit alcohol A
  • Control obesity and hypertension; for the latter, with cautious use of diuretics. B
    • Thiazides can cause an increase in uric acid [because they reduce the clearance of uric acid], so consider discontinuing HCTZ
  • Lower meat and fish consumption and decrease thick creams from diet. C
  • Avoid IV contrast dye because of the decreased glomerular filtration rate of uric acid.

A clinical decision rule with the variables: male sex, previous patient-reported arthritis attack, onset within 1 day, joint redness, first metatarsophalangeal joint involvement, hypertension or 1 or more cardiovascular diseases, and serum uric acid level exceeding 5.88 mg/dL was predictive of gout (receiver operating characteristic = 0.85; 95% CI, 0.81-0.90).

Plan:

The acute treatment goal is relief of pain using NSAIDs, colchicine, or steroids.

Joint aspiration if possible: checking for monosodium urate (MSU) crystals present in synovial fluid.

Joint aspiration is recommended, when possible, with examination of joint fluid for urate crystals under polarized light microscopy. Crystals are needle-shaped and are strongly negatively birefringent under polarized light. Crystals are only found 85% of the time, but when present are very specific for gout.

When the diagnosis is in question, joint aspiration should be attempted to confirm the presence of MSU crystals; if unsuccessful or the patient refuses, a good response to a trial of colchicine supports the diagnosis.

***Start Colcrys (Colchicine) today: 0.6mg tablets – Take 2 tablets with acute pain (now) and 1 tablet 1 hour later.

Discontinue HCTZ 25mg PO qd as this may be contributing to an increase in uric acid, and consider increasing the dose of current HTN meds other than HCTZ.

Measure serum uric acid level. Obtain 24 hours urine uric acid level too (Uric acid level (level normal in about 50% of gouty attacks). Serum uric acid > 7 mg/dl (men) or > 6 (women)

Consider 24-hour urine uric acid level, although there is poor patient adherence with the low-purine diet needed for an accurate test.

The patient is encouraged to limit her alcohol consumption, control her obesity and HTN, and to decrease her meat and heavy cream consumption.

Ex clinic Tx plan:

  • Prednisone 20mg PO – take 2 tablet qd for 5 days.
    • Prednisone may be given rather than NSAIDs due to patient’s lower renal function. Watch OTC pain medications due to low kidney function. Encourage more water intake.
  • NSAID (Ibuprofen)
  • Look for medications that may increase uric acid level and D/C them (ex: HCTZ).
  • Close F/U: 1-2 weeks.
  • Order Uric Acid level.
  • If flare in large joint, attempt joint aspiration. Otherwise (great toe), no aspiration attempted.

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